P - 76681IJinnesota Dep enf of Labor and Industry
443 Lafayette. oad North
Si Pauf, M 5155-4342
Phone: (6 2845064
T1Y/MR (651) 297-4198
wvrw.ele 'citv.state.mn.us
� Homeowner R
Date Rough-fn tnspecii�n Required?
�' i� �� Homeowner Must Schedule All Rou h-In
Address of Inspection - Street
ni�S'v,�v Qw �
Owner Name
�o �, QA � �-N
Owner Telephone Number(s) - Include Area Code(s)
?c� 3- s � � - 3 �� �
Owner Maiting Address — Street
'�..,_ z
RESIDENTIAL ELECTRICAL PERMIT BY HOMEOWNER
PERMIT # ��� �� - � I �Y�
RECEIVED: �SEP 7' %nn%
:$� for Electricaf Ins ection
Yes Inspecfion Oiher Than Rough-ln: ❑ Ready Now.
�ections Homeowner Must S�hedufe Ail Final !ns ections ❑ WII Schedule
City/Township County
��' � �L�� ,�rvoill�
Project Descripii
Movc" ��xe�Tl••.� f2,�c�;p?�c9� t
�AOp�ns �NC? i�Ot��?/UNf►� 2C:�'
s
r t w��k��J
City State Zip Code
Owner E-mail Address t�ectncai umrcy
��1L�C N� I�SG O, t�1 L��
By signing this do , certify fhat 1 am the owner as defined by Minn. Stat § 326.01 and �nrill legally perform the electrical work
Owner Signatur
Fee Calculation
New Home or Associated Structure Ezisting HomelStructure Remodel or Addiiion
New Home Service/Power Supply 0- 400 ampere @$35
New Home Senricelf'ower Supply 401 - 800 ampere @$60
New Home Feeders/Circuits
Up to 30 Feeders/Circuits - $100
New Home - More than 30 Feeders/Circuits (in add'Rion to
above) ( ) Feeders/Circuits Up To 200 A@$6 Each
Other (Specify)
Detached Garage or Other Associated Structure
New Service/Power Supply
New Feeders/Circuits
0 - 400 ampere @ $35
( ) @ $6 Each
New Service/Power Supply
�1Power Su�spiy
.rs/Circuits - Up to 15
FeedersJCircuits @ $I
.��r��„��r� _ nn„ro n,
� - 400 ampere � $35
401 - 8W ampere @ $60
16to30(c�$100
3D Feeders/Circuits
to 200 A (D_ $6 Each
( ) Feeders/Circuits $2 Each �
Detached Garage or Other Associated Structure
New 5ervice/Power Suppty
New Feeders/Circuits
Reconneded Feeders/Circuits
0 - 400 ampere @ $35
( ) @ $6 Each
( ) @ $2 Each
Tot31 (the fee calculated above or $35 multiplied Tot81 (the fee calculated above or $35 multiplied
by the number of required inspection trips, , by the number of required inspection trips, —7�
whichever is greater) whicheVer is greater) �, `(/
Requests for Elecirical Inspection (REI) with a fee of $250 or less exp[re 12 months from the filing date. The owner must have the work completed within the
12 month period or submit another REI that includes the inspectlon fee for the uncompleted work. Inspection fees do not carry over from one REI to another.
A service char e of S30 will be added for all dishonored cn�cks.
I hereby certify that I inspeGed the electrical instatlation herein on the dates stated: For Department Use Onfy
Rough - In Inspection(s) � Date
� L ��°� � �
Final lnspect Date
Z-?7-c
This material can be made available in different forms, such as large print, Braille or on a tape. To request,
TDD (651) 297-4198.
REI 01 (6/07)
1-B00-342-5354 (DIAL-DLI) Voice or